Facial Soft Tissue Infections

Heather Patterson

PGY-4

November 13, 2008

Objectives

• By the end of this session the learner will be able to outline clinical features, management strategies, and complication of facial infections including:– Cellulitis– Erysipelas – Orbital Cellulitis– Periorbital Cellulitis

Cellulitis

• Def’n:– Soft tissue infection of the skin and subcutaneous tissue

• Risk Factors:– Skin trauma– Lymphatic or venous stasis– FB– Immunosuppression

Cellulitis

• Clinical Features:– Skin:

• Red, swollen, warm, painful

• Blanching • +/- lymphadenopathy

– Vitals• +/- tachycardia, otherwise normal vitals

– Labs:• Minimal change to WBC

– Pertinent negatives• Fever uncommon• No crepitus or bullae

Cellulitis

• Ddx:– Orbital/preorbital– Erysipelas– Impetigo– Folliculitis– FB– Fascitis– Myositis– Post surgical healing– Burn

Cellulitis

• Bugs and Drugs:– Staph and Strep– Gram negative– MRSA

Erysipelas

• What is erysipelas?• What does it look like?• Who get erysipelas?• How do we treat it?

Erysipelas

• What is erysipelas?– Superficial cellulitis involving dermis, lymphatics, and most of the superficial subcutaneous tissue

Erysipelas

• What does it look like?– Sharply demarcated border +/- vessicles at margin

– Raised– Dark erythema– Indurated

• Other features:– Toxic appearing pt with prodrome of fever, chills, malaise,vomiting

– Rapid spread, very painful, itchy, burning

– Prominent lymphadenopathy

Erysipelas

• Who gets this?– Young or >50y– Risk factors:

• EtOH abuse, venous stasis, DM, nephrotic syndrome

– Associated with small breaks in the skin, post operative infections

Erysipelas

• How do we treat it?– MCC Group A Strep

• Pen G or erythromycin

– Cephalosporins, macrolides, fluoroquinolones for more severe cases

Orbital and Periorbital Cellulitis

• Anatomic differences

• Epidemiology• Pathophysiology• Clinical Features• Management• Complications

Orbital and Periorbital Cellulitis

• What is the difference in the location of infection?– Periorbital - preseptal– Orbital - posterior to the orbital septum

Orbital and Periorbital cellulitis

Orbital and Periorbital Cellulitis

• What is the population at risk? (i.e. epidemiology)– Children / adolescents + older pts

• Pathophysiology:– Extension from surrounding infections:

• Coexisting sinusitis in 80% • Dental infections

– Direct innoculation: • Facial trauma

– Hematogenous spread– Vascular lesions, chemical agents

Orbital and Periorbital Cellulitis

• What are the common bugs involved?– Staph and strep– Hflu (if unimmunized)

• Differentiate between the clinical presentation of the 2 entities:– Skin findings– Occular findings

Orbital and Periorbital Cellulitis

Periorbital Orbital

Erythema/edema

Around eye, eyelid

+/- Around eye, eyelid

Occular pain at rest

- +

Visual Acuity/fundi

N abN

Proptosis - +

EOM Full EOMNon painful

Limited EOMPainful

Conjunctiva Occ. ecchymosis

+/-

Orbital and Periorbital Cellulitis

Orbital and Periorbital Cellulitis

• What are the complications associated with orbital and periorbital cellulitis?– Orbital cellulitis:

• Orbital abscess• Subperiostal abscess• Loss of vision• Optic neuritis• Retinal vein thrombosis

– CNS extension• Meningitis, abscess• Cavernous sinus thrombosis

Orbital and Periorbital Cellulitis

• What are the management strategies?– Orbital

• Rapid dx - CT • Ophtho consult• Abx: amp/gent/flagyl or Clinda/gent or Ceftriaxone/flagyl

• What about lateral canthotomy? Indications? Procedure?

– Periorbital• R/O orbital ceullulitis• Abx: Cefuroxime x 2/7 and then po• Admit if unwell or indicated by social situation

Lateral Canthotomy

• Goals: – Rapidly decrease IOP– Reinstitute retinal artery blood flow

• Steps– Simple, rapid saline cleaning of lids– Anesthetize with 1-2% lidocaine with epi– Crush lateral canthus 1-2min with hemostat– Incise lateral canthus with iris scissors– Incision extends toward orbital rim– Identify superior and inferior crus of lateral canthal tendon

– Release inferior canthal tendon

Cavernous Sinus Thrombosis

Cavernous Sinus Thrombosis

• Clinical Presentation– Headache, fever, malaise– Face:

• Midface infection or sinusitis

• Periorbital edema, proptosis, ptosis, orbital pain, chemosis

– Occular exam• Sluggish pupillary response, decreased acuity, papilledema,

– CNS:• CN findings (CN VI first)

EOM• Mental status changes, confusion, drowsiness

Cavernous Sinus Thrombosis

• Management:– Early diagnosis – Early Abx– Anticoagulation?

• Bhatia et al 2002

– Steroids– Surgery is NOT indicated